Amerigroup Coverage Criteria
Latest Amerigroup coverage criteria updates10
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Site-of-care requirements for specialty drugs (site-of-care drug list)Defines which specialty drugs (medical benefit) require a site-of-care clinical review and notes interaction with existing clinical criteria, step therapy, and quantity limits; applies to Amerigroup members in the Georgia markets listed.All Amerigroup updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-09-11Reimbursement Policy Modifier 78Defines when Amerigroup will reimburse claims billed with CPT modifier 78 for unplanned returns to the operating or procedure room during the postoperative period and how reimbursement is calculated; applies to providers submitting claims to Amerigroup per contract and regulatory requirements.All Amerigroup updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2019-04-01Harvoni (sofosbuvir/ledipasvir) coverageDefines prior authorization, approval durations, and clinical criteria for covering Harvoni (sofosbuvir/ledipasvir) for treatment of chronic hepatitis C in eligible members.All Amerigroup updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-04-01Olysio (simeprevir) — Prior Authorization and Coverage CriteriaDefines Amerigroup pharmacy coverage, prior authorization, quantity limits, approval durations, and clinical criteria for use of Olysio (simeprevir) in treatment of chronic hepatitis C in adults.All Amerigroup updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-04-01Ombitasvir + paritaprevir + ritonavir + dasabuvir (Viekira Pak / Viekira XR) — Coverage CriteriaCovers prior authorization and medical necessity criteria for use of ombitasvir/paritaprevir/ritonavir with dasabuvir (Viekira Pak, Viekira XR) for treatment of chronic hepatitis C genotype 1 in eligible members; applies to Amerigroup pharmacy benefits (not Medicare or plans without pharmacy benefits).All Amerigroup updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-04-01Vosevi (sofosbuvir/velpatasvir/voxilaprevir) coverageDefines prior authorization, approval durations, and medical necessity criteria for Vosevi (sofosbuvir/velpatasvir/voxilaprevir) for treatment of chronic hepatitis C in adults; applies to Amerigroup plans with pharmacy benefits (not Medicare).All Amerigroup updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-04-01Zepatier (elbasvir/grazoprevir) — Coverage CriteriaDefines prior authorization, quantity limits, approval durations, and clinical criteria for coverage of Zepatier (elbasvir/grazoprevir) for members with hepatitis C; applies to Amerigroup pharmacy benefits (excludes Medicare and plans without pharmacy benefits).All Amerigroup updates
- Coverage CriteriaClinical/Medical PolicyEff. 2010-08-18Therapy for Children's Disabilities - Georgia PlanDefines medical necessity, documentation, authorization and coverage criteria for speech, occupational and physical therapy for children with developmental disabilities under Amerigroup's Georgia Medicaid plan (EPSDT). Affects providers requesting outpatient therapy for eligible pediatric members.All Amerigroup updates
- Coverage CriteriaClinical/Medical PolicyEpclusa (sofosbuvir/velpatasvir) prior authorization and coverageDefines Amerigroup prior authorization, approval durations, quantity limits, clinical criteria, and exclusions for Epclusa (sofosbuvir/velpatasvir) for treatment of chronic hepatitis C in adults.All Amerigroup updates
- Coverage CriteriaClinical/Medical PolicySovaldi (sofosbuvir) coverage criteriaDefines prior authorization, approval duration, quantity limits, and medical necessity criteria for Sovaldi (sofosbuvir) for treatment of chronic hepatitis C virus (HCV) infection for Amerigroup members.All Amerigroup updates
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Tool Description
Search Amerigroup coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
Coverage Criteria by Payer
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